Skin cancer risk factors
Risk factors for malignant melanoma of the skin and non-melanoma skin cancer (NMSC) are discussed on this page. These include ultraviolet radiation (from sun exposure and sunbeds), skin type and hair and eye colour, sunscreen use, family history, previous cancer, and other medical conditions.
Malignant melanomas can also occur in other body organs, such as the eye, but such melanomas are not discussed here. On this page “malignant melanoma” refers to malignant melanoma of the skin only.
In the sections which follow, meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and often take study quality into account. Individual case-control and cohort studies are reported where good quality aggregated data are lacking.
On this page:
- Ultraviolet radiation from sun exposure
- Ultraviolet radiation from sunbeds
- Skin type, hair and eye colour
- Moles (naevi)
- Sunscreen use
- Vitamin D
Excess exposure to ultraviolet (UV) radiation is the main preventable risk factor for skin cancer.1,2 The sun is the principal source of natural UV radiation (Figure 4.1). Sunbeds produce artificial UV radiation.
Figure 4.1: Solar UV Radiation in Relation to the Earth and Ozone Layer
UVA and UVB are the two types of solar radiation which reach us on Earth. Both types are linked to skin cancer. UVB is predominantly responsible for burning, whilst UVA penetrates deeper into the skin and is linked with premature ageing.
It is also expected that climate change will cause more skin cancer cases in the future, as more UV radiation reaches us on Earth, and warmer temperatures encourage people to spend more time in direct sunlight.98
There is sufficient evidence that too much exposure to solar UV radiation is the main cause of both malignant melanoma and NMSC in humans, according to the International Agency for Research on Cancer (IARC).3,4 It is estimated that around 11,100 (86%) malignant melanoma cases in the UK in 2010 were linked to UV radiation exposure.1 Among NMSCs, an estimated 50-70% of squamous cell carcinomas (SCCs) and 50-90% of basal cell carcinomas (BCCs) in fair-skinned people are caused by UV radiation.5
Intermittent sun exposure and sunburn
Risk of malignant melanoma is most strongly linked to intermittent exposure to high-intensity sunlight (for example from sunbathing, doing watersports or holidaying in a place where the sun is strong), a meta-analysis has shown.6 Intermittent sun exposure was associated with a 60% increased risk of malignant melanoma, though this effect was smaller and not significant in studies of UK, US, Canadian or Australian populations.6
Intermittent exposure to high-intensity sunlight often results in sunburn,6 and a history of sunburn doubles the risk of malignant melanoma.6,7 Having had 26 or more episodes of ‘painful’ or ‘severe’ sunburn during your lifetime increases the risk of malignant melanoma by two to three times in women, a pooled analysis showed.8 Malignant melanoma risk is increased regardless of whether sunburn occurred in childhood or adulthood.6,9
Sunburn, especially in childhood, or intermittent exposure to sunlight, also increases the risk of BCC.10,15 Sunburn and intermittent sunlight exposure is believed to have less of an effect on SCC risk.12,14,16
Exposure to UV radiation has increased in recent decades in the UK population, as people have increasingly sought a suntan by holidaying abroad.
Chronic sun exposure
Chronic or more continuous sunlight exposure, for example that received by people with outdoor occupations, did not appear to increase malignant melanoma risk in a recent meta-analysis, though the review authors commented that occupational sun exposure still probably increases risk over no sun exposure at all.6
There is evidence that chronic sun exposure increases the risk of NMSC. People who work outdoors are at 43% higher risk of BCC,17 and 77% higher risk of SCC,18 and these effects are stronger in countries nearer the equator, two meta-analyses have found.17,18
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There is sufficient evidence that use of sunbeds causes malignant melanoma, IARC states.4 IARC also states there is limited evidence that sunbed use causes SCC.4 There is currently no IARC statement on sunbeds and BCC.
Use of a sunbed for the first time before age 35 increases the risk of malignant melanoma by 59%, and use at any age increases malignant melanoma risk by 20-25%, the most recent meta-analysis showed.19,103 Women using a sunbed once a month or more in their 30s increase their malignant melanoma risk by 49%, and those doing so in their 40s face a 61% increased risk, one large study included in that analysis showed.20 Another cohort study showed women aged 25-39 who use a sunbed more than 10 times a year have two-and-a-half times the malignant melanoma risk compared with women who do not use sunbeds.123 Sunbed use is estimated to cause around one hundred deaths a year from malignant melanoma in the UK.19,21
Sunbed use at any age increases the risk of SCC by 67%, and increases BCC risk by 29%, according to the most recent meta-analysis.101 Risk increases for both types of NMSC in relation to sunbed use were also shown in an earlier meta-analysis.19 Exposure before age 25 appears to confer even greater risk increases, though in meta-analysis the effect was significant only for BCC (40% risk increase).101 Women who used a sunbed more than six times a year during high school increased their BCC risk by 73% in comparison with those who didn’t use a sunbed, a US cohort study showed.120 And both SCC and BCC risk were increased by 15% for every four sunbed sessions a year during high school or at age 25-35.120
Using a sunbed without ever burning appears to be no safer – it can increase the risk of malignant melanoma and early-onset BCC (diagnosed in people under 40 years old) by more than 60%, recent case-control studies have shown.22,23
Prevalence of sunbed use
In 1999 a quarter of men and a third of women in Britain reported trying to get a tan in the previous six months. There were even higher rates amongst younger people (Figure 4.2). Overall, 2% of adults trying to get a tan did so using a sunbed or tanning machine only.24 In 2008 and 2009, 6% of 11-17-year-olds in England reported they had used a sunbed,25 and in 2008, 5% of under-25s in Northern Ireland reported currently using sunbeds.26
Figure 4.2: Proportion of Adults that Tried to get a Tan in the Last Six Months, Great Britain, 1999
Download this chart XLS (55KB)
The possibility that younger people and those with high-risk skin types are at greatest risk of skin cancer due to sunbed use is widely recognised. In 2003 the International Commission on Non-Ionizing Radiation Protection (ICNIRP) and the World Health Organisation (WHO) recommended that certain categories of people should not use sunbeds (Table 4.1).27,28 ICNIRP also concluded that anyone using suntanning appliances is likely to raise their risk of skin cancer, eye damage, photodermatosis, photosensitivity and premature skin ageing.27 Cancer Research UK recommends that people do not use sunbeds.
Table 4.1: Categories of People who Should Not Use Sunbeds, as Recommended by ICNIRP and WHO
|People who have skin phototypes I or II (see Table 4.2 for definition)|
|Children (i.e. less than 18 years of age)|
|People who have large numbers of naevi (moles)|
|People who tend to freckle|
|People who have a history of frequent childhood sunburn|
|People who have pre-malignant or malignant skin lesions|
|People who have sun-damaged skin|
|People who are wearing cosmetics - these may enhance their sensitivity to UV exposure|
|People taking medications which make them UV-sensitive.|
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People with light eyes, skin or hair, or with skin that sunburns easily or does not tan, have an increased risk of skin cancer.10,11,14,29,30 These factors in combination are used to define the skin phototype (Table 4.2). This classification is used in most studies exploring pigmentary characteristics and skin cancer risk.29
Table 4.2: Skin Phototypes
|Skin Phototype||Typical Features||Tanning Ability|
|Type I||Tends to have freckles, red or fair hair, and blue or green eyes.||Often burns, rarely tans.|
|Type II||Tends to have light hair, and blue or brown eyes.||Usually burns, sometimes tans.|
|Type III||Tends to have brown hair and eyes.||Sometimes burns, usually tans.|
|Type IV||Tends to have dark brown eyes and hair.||Rarely burns, often tans.|
|Type V||Naturally black-brown skin. Often has dark brown eyes and hair.|
|Type VI||Naturally black-brown skin. Usually has black-brown eyes and hair.|
Based on: Fitzpatrick T. Soleil et peau. J Med Esthet 1975;2:33-4.
In comparison with people with skin phototype IV, those with skin phototype I are at more than double (2.27 times) the malignant melanoma risk, phototype II at double (1.99 times) the risk, and phototype III at 35% increased risk, a recent meta-analysis reported.29
Table 4.3 gives incidence rates for malignant melanoma by major ethnic group in England.31
Table 4.3: Ranges of Age-Standardised Incidence Rates per 100,000 Population for Malignant Melanoma, 2002-2006 by Major Ethnic Group and Sex, England
In comparison with dark-eyed people, those with blue/blue-grey eyes have a 57% higher malignant melanoma risk, and those with green/grey/hazel eyes have a 51% increased risk.29
In comparison with dark-haired people, those with red/red-blonde hair were shown to be at up to triple the malignant melanoma risk.29,32 Blondes are at double the risk, and people with light brown hair are at 46% increased risk.29
People with freckles were found to have around double (1.99 times) the risk of malignant melanoma, versus people without freckles.29 People with freckles have increased malignant melanoma risk, regardless of the number of moles they have.33
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Meta-analyses show people with any unusually shaped or large moles (also called atypical naevi; these are usually larger than common naevi, with a more variegated appearance; poorly-defined border, and some areas slightly raised) have around four to ten times increased risk of malignant melanoma,38,39 and the risk increases with the number of atypical moles.38 People with very high numbers (100+) of common moles on their bodies have nearly seven times the risk compared to people with very few (0-15 moles),38 and every additional common mole increases the risk of malignant melanoma by around 2%.39
People with dysplastic mole syndrome (also known as Familial Atypical Multiple Mole-Melanoma Syndrome or FAMMM; characterised by multiple atypical moles that continue to appear in adulthood) and a family history of malignant melanoma have a 500-fold increased risk of developing malignant melanoma;40 however this is very rare and accounts for less than 5% of malignant melanoma cases.38
Most moles are genetically determined (inherited), though sun exposure can increase the number of moles. Most moles appear during childhood.33,41 The emergence of moles in adolescents is under strong genetic control, a UK study of moles in twins concluded.42 Chronic sun exposure rather than number of sunburn episodes is the most important environmental factor determining mole development.33
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The impact of sunscreen use on skin cancer risk remains unclear, due largely to methodological limitations.43,44
Sunscreen should be used together with clothing and shade to protect the skin from sun damage, and should never be used to spend longer in the sun. Research shows sunscreen users may counteract the protective effect of sunscreens by: spending longer in the sun than non-users; applying their sunscreen incorrectly; or failing to use protective clothing.45-48
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The only established benefit of exposure to solar UV radiation is the synthesis of vitamin D, which is vital for bone health. Higher circulating levels of vitamin D in the blood are associated with lower risk of bowel cancer, although it is unclear whether this is a causal relationship.49-53
However, sunbathing, tanning or burning should not be necessary to make sufficient vitamin D to obtain health benefits. In fair-skinned people, the time taken to make enough vitamin D is short, and less than the time taken for skin to redden or burn.54 Once sufficient vitamin D is made, any extra is turned into inactive substances.55 So more sun exposure does not equate to greater health benefits, and excessive exposure to solar UV radiation is not a means of reducing the incidence or mortality of cancer.
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People with a family history of malignant melanoma have roughly double the risk of developing the disease, compared to people without a family history.56,57 A small percentage of malignant melanoma cases (around 10%) are attributable to inherited risk.58,59
FAMMM is one of several rare hereditary syndromes associated with an increased risk of malignant melanoma.60 FAMMM is associated with the hereditary susceptibility genes CDKN2A and CDK4. CDKN2A mutation carriers often have three or more family members with malignant melanoma, or have multiple primary malignant melanomas with no family history. CDKN2A mutation carriers living in Europe have a ∼58% risk of developing malignant melanoma by age 80.61 Malignant melanoma and NMSC have been linked to Li Fraumeni syndrome in some studies, although they are not among the ‘core’ cancers occurring in Li Fraumeni families.62
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Previous malignant melanoma is associated with eight- to twelve-fold increased risk of a second malignant melanoma.65,66,116 The effect is stronger for women.65,66 People with a previous malignant melanoma and a parent with malignant melanoma are at more than 30-fold risk of a second malignant melanoma.67 Malignant melanoma risk is higher among people with a previous diagnosis of various other cancers, including female breast cancer;68,69 non-Hodgkin lymphoma;70,71 renal cell carcinoma;72 certain childhood cancers;73,115 prostate cancer;68,74,125 thyroid cancer;68 and leukaemia.68 Generally the increase in risk was less than double. Often these associations are bi-directional,66 supporting shared genetic or environmental factors.
Previous SCC is associated with ten times higher risk of a second BCC or SCC, whilst previous BCC is associated with ten times higher risk of second BCC but a lower increase in second SCC risk.75-77 Previous malignant melanoma is associated with three-fold increased risk of NMSC.78 People who have had NMSC are also at increased risk of other second primary cancers.79
section reviewed 05/12/13
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Organ transplant recipients are at 29-fold increased NMSC risk, and two-fold increased malignant melanoma risk, a meta-analysis shows.80-82 This may be related to the use of immunosuppressant drugs called azathioprine and cyclosporine, which IARC states are causes of NMSC.4
People with Crohn's disease have an 80% increased risk of malignant melanoma, and people with ulcerative colitis have a 23% increased risk, a meta-analysis shows.107 Treatment for these bowel conditions may include immunosuppressant drugs, but the increase in malignant melanoma risk appears to be independent of treatment.107
People with atopic dermatitis (the most common form of eczema) appear to have an increased risk of NMSC, but the association between atopic dermatitis and malignant melanoma remains unclear.83,84 Contact allergy may reduce the risk of NMSC very slightly.85 A drug called methoxsalen is used in conjunction with exposure to UVA to treat eczema, and IARC classifies this as a cause of NMSC.4 Patients with severe psoriasis may have seven times the NMSC risk of the general population, and eleven times the malignant melanoma risk, a cohort study showed.113
Malignant melanoma risk is apparently doubled in men with Parkinson’s disease, but there is no significant association for women, a meta-analysis showed.86 Subsequent cohort studies have found a smaller effect (41%-53% increase in men and women combined) with similar magnitude in both sexes.121,124 NMSC risk was 29% higher in Parkinson’s disease patients in that cohort study, but the meta-analysis found no significant association.86,121
Rheumatoid arthritis patients taking tumour necrosis factor inhibitors (anti-TNF-α) may have increased NMSC risk, but the evidence remains unclear: a meta-analysis of randomised controlled trials found the effect was not significant,109 but a meta-analysis of observational studies found a 45% higher risk of NMSC.87 Rheumatoid arthritis patients taking anti-TNF-α do not have a higher NMSC risk than patients taking other disease-modifying anti-rheumatic drugs,99 not does their malignant melanoma risk appear to be significantly altered.87
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For every 5cm increase in height, malignant melanoma risk is 17% higher in females and 13% higher in males, and NMSC risk is 12% higher in females and 10% higher in males, a pooled analysis of Nordic data showed.127 One study showed women taller than 5 feet 3 inches were at 28-64% higher BCC risk than shorter women.34 Malignant melanoma risk in women increased by 32%-51% for every 10cm increase in height, according to recent large studies.88,100
Malignant melanoma risk is 31% higher in overweight (body mass index (BMI) 25-29.9) and obese (BMI 30+) men, compared with men whose BMI is lower than 25, a meta-analysis reported.108 This analysis showed the risk appears to plateau in overweight men rather than continuing to increase with higher BMI,108 however a previous meta-analysis found a 17% risk increase per 5-unit BMI increment. 89 Case-control studies show that women with higher BMI or body surface area have an increased malignant melanoma risk, when results are adjusted for the amount of sun exposure, suggesting mutual confounding between body size and sun exposure (e.g. larger women self-limit their public sun exposure).108 However, most studies have not adjusted for amount of sun exposure and have not found an association between overweight and malignant melanoma risk in women.89,90,108 Obesity is associated with decreased NMSC risk, perhaps due to less UV exposure in larger people.91,118 Women with BMI lower than 25kg/m2 were at 26-43% higher BCC risk and 20-41% higher SCC risk than women with a higher BMI, US cohort studies have shown.34,91 For men in these analyses, the difference in BCC risk was only significant for people with BMI 30-34.99 versus BMI under 25, and there was no significant effect of BMI on SCC risk.34,91 Babies with a higher birthweight have a higher risk of early-onset malignant melanoma, a Northern Ireland cohort study showed; those weighing 4.5-6kg at birth had more than twice the malignant melanoma risk compared with those weighing 3-3.5kg at birth.114
There is sufficient evidence that X-radiation and gamma radiation (both types of ionising radiation) cause NMSC, according to IARC.4 Radiotherapy for a previous cancer is estimated to have caused 17.9% of second primary malignant melanoma cases in women and 2.8% of second primary malignant melanoma cases in men in 2010.92 Exposure to cosmic radiation has been posited as an explanation for the higher rates of malignant melanoma in airline staff, but recent evidence suggests that excessive UV exposure and sun-sensitive skin phenotypes are more likely causes.93,94 People who receive at least one computed tomography (CT) scan of the brain before age 20 have a 14% higher risk of malignant melanoma or NMSC, with no significant effect of CT scans to other anatomical sites, a large Australian cohort study showed.112
Some chemical exposures that can take place in certain occupations cause NMSC, IARC states.4 These include coal tar pitch, soot, mineral oils and shale oils. It has been estimated that around 7% of NMSCs in men and around 1% in women in Britain are due to occupational exposures (including solar radiation).95
People diagnosed with genital warts (associated with infection with HPV types 6 and 11) have a 30% increased risk of BCC.102
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Use of oral contraceptives (OCs) or hormone replacement therapy (HRT) does not significantly impact on malignant melanoma risk in women, a meta-analysis shows.96 Other reproductive factors (age at birth of first child, number of children) show small effects on malignant melanoma risk, though these effects are largely explained by socio-economic factors.96 SCC risk increased by 35% for every five years of HRT use in a cohort study, and BCC risk was 15% higher in women who had ever used HRT compared to those who had never used it.122 OC use did not impact on BCC or SCC risk in this cohort study.122
Unlike for many other cancers, smoking does not appear to increase malignant melanoma risk .4,110 The relationship between smoking and NMSC risk remains unclear, with effects apparently varying by NMSC type, and patient sex.97,110 Alcohol consumption may increase malignant melanoma and NMSC risk, but findings remain mixed.4,117,126
Non-steroidal anti-inflammatory drugs (NSAIDs) appear not to affect malignant melanoma risk, meta-analyses show.104,105 Case-control studies indicate aspirin may slightly reduce malignant melanoma risk, but no effect is seen in cohort studies – and because of the potential adverse consequences of high intake of aspirin, such as gastrointestinal haemorrhage, it would not be recommended as a prophylactic measure.104,105
Low-fat diet does not appear to affect malignant melanoma risk in women, a US cohort study showed.111 Folic acid supplements were shown to have no effect on malignant melanoma risk in the largest meta-analysis to date,106 Vitamin A and carotenoids intake did not affect malignant melanoma risk in a large cohort study.119
section reviewed 06/12/13
section updated 06/12/13
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